Telemedicine and In-Person Visit Modality Mix and Electronic Health Record Use in Primary Care

This cross-sectional study investigates the association between day-to-day changes in telemedicine share and clinician time spent on electronic health record (EHR) use.


Introduction
Telemedicine use increased substantially during and after the COVID-19 pandemic 1 and has the potential to provide low-acuity medical services at lower costs. 2However, telemedicine also levies new costs on clinicians. 3Telemedicine requires shifting care delivery workflows, as it rarely includes clinical support staff but can involve levels of patient complexity similar to in-person visits. 4,5This may increase administrative and electronic health record (EHR) burden for clinicians and increase cognitive costs as clinicians switch modalities.In a recent study, 6 greater weekly telemedicine visit share was associated with increased EHR time, including after-hours time, mostly spent in documentation.Our study aimed to address 2 gaps: first, whether day-to-day changes in telemedicine share demonstrate a similar association with EHR time; and second, what changes occur in domains of EHR use not examined in previous studies (eg, medical record review, orders).The plots show estimates and 95% CIs from ordinary least squares linear regression models adjusting for daily visit volume, and physician and calendar day fixed effects.N = 67 894 for all outcomes except next-day documentation time (n = 47 297).Estimates and 95% CIs for 100% telemedicine days do not reach statistical significance and exhibit wide variation due to relatively few observations; thus, they were omitted for readability.
a Reference category is zero telemedicine visits.

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minutes on zero-telemedicine days and 87.1 (50.0) minutes on days with up to 10% telemedicine visits.In regression analyses, days with a mix of visit modalities were associated with significantly greater time for EHR, documentation, and medical record review (Figure).Compared with zerotelemedicine days, 26% to 99% telemedicine days were associated with 14.8 (95% CI, 7.6-22.0)more minutes of active EHR time (5.6% increase, P < .001),4.7 (95% CI, 1.2-8.3)additional documentation minutes (6.0% increase, P = .01),and 5.5 (95% CI, 2.8-8.2) additional medical record review minutes (6.2% increase, P < .001).Telemedicine share resulted in a negligible increase in order time and had no association with next-day documentation time (Figure).

Discussion
This cross-sectional study found that, during clinic days with both telemedicine and in-person visits, PCPs had 5.6% to 6.2% more EHR-based work.This work did not spill over into next-day documentation, suggesting that PCPs absorbed added time into their workload on mixed-modality days.However, we found that fully telemedicine days were not associated with EHR-based work, contrary to previous findings. 6We attribute this difference to the small sample of fully telemedicine PCP-days in our study in comparison with prior work 6 (2.2% vs 16.5% of physician-weeks) as well as higher mean visit volume (13.9 visits/d vs 20 visits/wk) (Table ).Greater EHR time may be due to increased multitasking during telemedicine visits, as PCPs simultaneously engage with patients and the EHR during telemedicine visits in ways that are not possible in person.This multitasking may feel more efficient and therefore may not register as "burdensome"; further research should explore whether added EHR time associated with mixed-modality days further burdens PCPs.Limitations of our study include our setting of a single health system, lack of information on visit and patient characteristics and on clinicians' experience with telehealth tools, and lack of clinical outcomes.

JAMA Network Open | Health Informatics
Share of Telemedicine vs In-Person Visits and Clinician Time Spent in EHR

Figure .
Figure.Daily Telemedicine Visit Share and Electronic Health Record (EHR) Time Outcomes 25

Table .
Results for All Outcomes Stratified by Daily Telemedicine Share a a The table shows descriptive statistics of outcomes and model covariates across daily telemedicine share categories.All bivariate differences are significant at the P < .001level.bOur sample included PCP-days with at least 4 patient visits.
This cross-sectional study combined visit modality data with EHR active use data capturing time spent by primary care physicians (PCPs) in the Cerner EHR system from December 2021 through June 2023 at MedStar Health, a large multispecialty health system in the mid-Atlantic region.We calculated PCPs' daily telemedicine share as the percentage of the day's visits conducted via telemedicine and categorized this variable into 5 levels.Because we used deidentified data, this study was deemed exempt and not human participant research by the Georgetown University- Open. 2024;7(4):e248060.doi:10.1001/jamanetworkopen.2024.8060(Reprinted) April 24, 2024 1/3 Downloaded from jamanetwork.comby guest on 04/26/2024 Methods